Occupational Therapy Case History Form

Please fill out this form as completely as possible. This information is crucial for our evaluation process; your input gives us insight into your child's every day level of functioning. If you answer yes to any questions please try to give comments.

*Please Note: After completion, please return this form, along with any other pertinent academic/medical information (i.e. IEP, reports from other clinicians or therapists your child has seen) to the center at least one week prior to the scheduled evaluation.

Patient Information